Head, Neck And Breast Surgery Flashcards
List the non-hereditary risk factors for breast cancer
Older patient >50 years
Females
Alcohol and smoking
Early menarche
Late menopause
Late first pregnancy/few or no pregnancy
Obesity
List the hereditary risk factors for breast cancer
BRCA 1 or BRCA 2 mutation
* BRCA 1 mutation - 85% chance of developing breast ca
Family history of breast cancer
Family history of ovarian cancer
Personal history of breast cancer
What patients are considered high risk for breast cancer?
> 1 first line relative with unilateral breast ca
1 first line relative with bilateral breast ca
1 male relative with breast ca
1 relative with breast or ovarian ca
Previous biopsy showing
- CIS
- Proliferative disease with atypia
- complex fibroadenoma
How is breast cancer diagnosed?
Triple Test!!
- Clinically
* History - Risk factors
* Exam - Lump/mass and LN
* Metastases - Mammogram
* 2 views - CC and MLO
* Suspicious lesion - FNA and Cytology
* ER/PR status
* Pathological type
* Inconclusive > Core biopsy
What is the importance of ER/PR status of a breast carcinoma
ER/PR (+) must NOT get hormone Replacement therapy because it feeds the tumour
What are the features of a suspicious lesion on mammogram?
Hyperdense
Spiculated
Pleomorphic microcalcifications
What are the most common pathological types of breast cancer?
Infiltrating ductal (75%)
Infiltrating lobular (10%)
What are the management guidelines for a Stage I-II breast cancer?
Breast conservtaion therapy with adjuvant radiotherapy
Systemic therapy depending on prognostic factors of the tumor
What are the indications for Neo-adjuvant chemotherapy in breast cancer?
All locally advanced disease - Stage IIb; IIIa and IIIb
> 4cm mass
To downstage a tumor
If increased risk of micrometastases
To decrease tumour size
HER (+)/(-)
Triple negative - ER/PR/HER (-)
What are the indications for Adjuvant chemotherapy in breast cancer?
Age <40 years
ER / PR (-)
> 3 LN involvement
High grade tumours
What are the indications for hormone therapy in breast cancer?
ER (+)
Soft tissue metastases
Bone metastases
Pleural effusion (lung metastases)
Local reccurrance
What are the indications for a mastectomy (contraindications for BCT) in breast cancer?
High breast : tumour ratio
Previous irradiation to the breast
Multifocal/multicentric tumour
Wide spread microcalcifications on mammography
Tumor > 4cm
BRCA (+)
Patient preference
Collagen vascular disease - coz’ radiotherapy C/I
- SLE
- Scleroderma
2 Recurrence of carcinoma
Males
Poor socio-economic circumstances
Pregnancy / Lactation
What hormone therapy would you use in a post-menapausal woman with breast cancer?
Tomoxifen
- Inhibits oestrodiol binding
- Especially effective in ER/PR (+) patients
Anastrozole (Arimidex)
* Aromatase inhibitor - inhibits the conversion of androgens to oestrogen
What are the side-effects of tomoxifen?
Menopausal symptoms:
- Hot flushes
- Mood changes
- Altered menses / amenorrhoea
- Dry vagina
- Thrush
Thromboembolism
- Stroke
- DVT
Fatty liver changes
Increased risk of endometrial cancer
Vaginal atrophy and bleeding
What are the side-effects of Arimidex?
MSK pain
Bone pain
What hormone therapy would you use in a pre-menapausal woman with breast cancer?
Ovarian ablation
- Surgical
- GnRH antagonist - Temporary, better for younger patients
Tomoxifen
What receives biological therapy in breast cancer and biologic would they receive?
HER-2 (+) patient
Herceptin - monoclonal antibody against HER-2
Discuss regional therapy in breast cancer
Palpable Axillary LN
* Axillary dissection via Modified radical mastectomy
Impalpable Axillary LN
* Sentinal LN biopsy
Discuss BRCA
Autosomal dominant inheritance
Associated with breast, ovarian, fallopian tube, colon and prostate carcinoma
What stage breast cancers would you do a CT scan and bone scan for?
Stage IIb and up
To look for Metastases
What are the histological indications for axillary dissection in breast cancer?
Large tumour
Soft tissue invasion
3 or more LN had tumour in it
Extranodal extension of disease
Micrometastases
What special investigations would you do in a patient with thyroid pathology and why?
Serum TSH
- Raised in hypothyroidism
- Decreased in hyperthyroidism and euthyroidism
Total T4, free T4 and free T3
* Function of the thyroid
Serum Calcitonin
* Increased in MEN 2 syndrome
Thyroid Antibodies
* Increased in autoimmune thyroiditis
Discuss the use of thyroid function tests (TFT)
Elevated TSH and low FT4 = Primary hypothyroidism due to disease in the thyroid gland
Low TSH and low FT4 = Hypothyroidism due to a problem involving the pituitary gland
Low TSH with an elevated FT4 and FT3 = Hyperthyroidism.
Discuss Radioactive Iodine (RAI) Uptake testing
Provides a function-anatomical correlation of thyroid lesion
Provides information on risk of malignancy
Cold nodule = High risk of malignancy (20%)
Hot nodule = Lower risk of malignancy (5%)
* Hot nodule + hyperthyroidism = benign
What imaging would you do in a patient with thyroid pathology and why?
RAI uptake
* Provides information of risk of malignancy
FNA
* Diagnoses/excludes malignancy
Ultrasound
* Evaluation of thyroid nodules for suspicious signs of malignancy
CT scan
* Metastases
What are the suspicous signs of thyroid cancer on ultrasound?
Calcification
Increased vascularity
Irregular borders
Absent halo sign
What is the most common thyroid malignancy?
Papillary cell adenocarcinoma
What is the origin of a Papillary cell adenocarcinoma of the thyroid?
Arises from follicular epithelial cells
What are the risk factors for a Papillary cell adenocarcinoma of the thyroid?
Genetic mutation of BRAF gene
Previous irradiation
Family history of thyroid cancer
Familial syndromes:
- Familial papillary carcinoma
- Familial non-medullary thyroid carcinoma
- Familial adenomatous polyposis coli (FAP)
- Gardner syndrome (Familial colorectal polyposis)
- Turcot syndorme (multiple adenomatous polyps in the colon)
What is the clinical presentation of a Papillary cell adenocarcinoma of the thyroid?
Most common (80%)
2:1 female:male ratio
20-30 years
Solitary nodule
- Firm on palpation
- Solid on ultrasound
- Cold on RAI
Dysphagia (invasive)
Dyspnoea (invasive)
Dysphonia (invasive)
Palpable LN
What is the route of spread of a Papillary cell adenocarcinoma of the thyroid?
Lymphatic
Where does a a Papillary cell adenocarcinoma of the thyroid metastasize to?
Lungs
Bone
What investigations would you do for a papillary cell adenocarcinoma of the thyroid??
Thyroid function tests
- Increased TSH
- Normal FT3 and FT4
Ultrasound
- Look for suspicious signs
- Solid
FNA and cytology
- Papillary projections of columnar epithelium
- Psammoma bodies (60%)
RAI
* Cold
What is the management of a Papillary cell adenocarcinoma of the thyroid?
Surgical
<1 cm - Lobectomy/Isthmustectomy (Younger patients)
>1 cm - Total thyroidectomy with central node dissection
Adjuvant
- Thyroid hormone suppression and radioiodine therapy
- External beam radiotherapy for >45 years and had locally invasive disease.
Post-Total thyroidectomy
Life-long thyroid hormone replacement therapy
What are the indications for a Total thyroidectomy?
(Also contraindications to RAI)
Large/Multinodular goitre with poor RAI uptake
Compression symptoms
Suspicious malignant nodule/ confirmed thyroid cancer
Pregnancy/children
Patients who wish to fall pregnant
Amioderone induced hyperthyroidism
Adverse effects of antithryoids
Unable to follow long term follow-up
What are the complications of thyroidectomy?
Thyroid storm
Neck haematoma
Recurrent laryngeal nerve injury
Injury to the external branch of the superior laryngeal nerve
Injury to the oesophagus
Injury to to the great vessels/cervical sympathetic trunk
Hypoparathyroidism
Provide a DDx for a solitary nodule of the thyroid
Cyst
Colloid nodule
Papillary cell adenocarcinoma
Follicular cell adenocarcinoma
What is the origin of a medullary carcinoma of the thyroid?
Arises from the parafollicular cells
*Secretes calcitonin and CEA
What are the risk factors for medullary carcinoma of the thyroid?
RET oncogene on chromosome 10
MEN syndrome 2A and 2B
What is the presentation of medullary carcinoma of the thyroid?
Sporadic type
* Unilateral, solid, hard, nodular neck mass
Familial type
* Bilateral/multicentric hard, nodular neck mass
What is the route of spread for medullary carcinoma of the thyroid?
Haematogenous
- LN
- Bone
- Lung
Where does a medullary carcinoma of the thyroid metastasize to?
Early
- Adjacent muscle
- Trachea
- Local and mediastinal LN
Late
- Bones
- Lungs
- Liver
- Adrenals
How would you diagnose a medullary carcinoma of the thyroid?
Bloods
- Raised Calcitonin
- Raised CEA
FNA
RAI
* Cold
How would you manage a medullary carcinoma of the thyroid?
(If present, phaeochromocytoma should be managed first)
Total thyroidectomy + modified neck dissection if cervical LN affect
Define MEN syndrome
It is a group of autosomal dominant disorders characterized by the growth of benign and malignant endocrine tumours
What are the clinical features of MEN-1 syndrome?
Hyperparathyroidism
Pancreatic tumours
Pituitary adenomas
Adrenal adenoms
Carcinoid tumours
What is the management of MEN-1 syndrome?
Hyperparathyroidism
- Medical - Calcimimetics
- Surgical - Parathyroidectomy with thymectomy
Gastrinomas
* Medical - PPI’s (omeprazole)
What are the clinical features of MEN-2A syndrome?
Medullary carcinoma of the thyroid (80-100%)
Phaeochromocytoma (40%)
- HPT
- Headaches
- Palpitations
- Diaphoresis
How would you diagnose MEN-2A syndrome?
Genetic testing - RET mutation
Serum calcitonin after 3 days of omeprazole
What is the management of MEN-2A/2B syndrome?
Medullary carcinoma of the thyroid
* Prophylactic thyroidectomy in kids with RET mutation
Phaeochromocytoma
- alpha-blockers + beta-blockers
- Unilateral/bilateral adrenalectomy
What are the clinical features of MEN-2B syndrome?
Medullary carcinoma of the thyroid
Mucosal neuromas
* Bumpy, enlarged lips and tongue
Phaeochromocytoma
- HPT
- Headaches
- Palpitations
- Diaphoresis
Skeletal abnormalities
Marfanoid habitus
What is the most common salivary gland neoplasm?
Parotid tumours - Benign pleomorphic adenoma
What is the clinical presentation of a malignant parotid mass?
Rapid growth
Pain
Paraesthesia
Facial nerve (CN VII) weakness/palsy
Skin invasion and fixation to mastoid tip
How would you diagnose a salivary gland tumour?
FNA
Surgical excision
* Provides a definite histopathological diagnosis
MRI
- Better soft-tissue visualization
- Can see soft tissue extension and involvement of adjacent structures
How would you manage a benign pleomorphic adenoma of the parotid gland?
Superficial parotidectomy with preservation of the facial nerve
What are the indications for adjuvant radiation therapy in salivary gland tumours?
Extraglandular disease
Perineural invasion
Direct invasion of regional structures
Regional metastases
High-grade histology
